Department of Civil Service

NY20-09
PE20-06

TO: All Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Revised M/C Life Forms
DATE: May 27, 2020

The Employee Benefits Division (EBD) has revised the following M/C Life forms:

• PS-934 M/C Life Insurance Transaction Form
• PS-934.1 M/C Life Insurance Beneficiary Designation Form
• PS-932 M/C Life Insurance Transition to Retirement Notice

Effective immediately, please discontinue use of all prior versions of these forms. The new version of the form is available on HBA Online at:

https://www.cs.ny.gov/employee-benefits/hba/shared/publications-and-order-forms/

Choose the appropriate group. Then, under NYSHIP Insurance Forms and Support Materials, click on Choose the category and then Management/Confidential (M/C) Life Insurance.

Enrollees can find the Transaction form and Beneficiary Designation form on the M/C Life Insurance site: https://www.cs.ny.gov/otherben/life/mclife.cfm

To navigate to it, go to the Department of Civil Service homepage https://www.cs.ny.gov/, choose the State Employees dropdown menu and click the Resources link. On the next page, click the Life Insurance link in the Health Insurance and other Employee Benefits section.

There have been no changes to the M/C Life Insurance eligibility requirements.

These revisions are intended to make the forms more user friendly by clarifying eligibility and documentary requirements. Most notably, EBD has created a customized Beneficiary Designation form to replace the MetLife Form, which is more consistent with EBD formats. These changes will also make the forms easier for enrollees to submit and easier for HBAs and EBD staff to review.

Now that the form is available online, paper copies of the M/C Life Insurance Transaction Form are no longer available for order.

As a reminder:

• The M/C Life Insurance Transaction form (PS-934) must be submitted within six pay periods of an appointment to a M/C position. If the transaction form is not received timely, a Statement of Health form (SOH-ST100M-NY 8/15) is required for the enrollee and any dependent(s) for whom they are requesting coverage.
• The Beneficiary Designation Form (PS-934.1) must be submitted with the initial enrollment and the enrollee may change their beneficiary at any time by submitting a new PS-934.1 form.
• The M/C Life Mandated Package includes a copy of the M/C Life booklet, but it will no longer include copies of the M/C Life Insurance forms PS-934 and PS 934.1. The cover letter has been updated with instructions to locate them online.
• The Transition to Retirement Notice (PS-932) should be included in the pre-retirement package you provide to all M/C employees enrolled in life insurance and the enrollee should submit the completed form by the date of retirement.
• The instructional document, M/C Life Insurance New Retiree Information (PS-931), is obsolete and has been removed from HBA Online since the Transition to Retirement Notice (PS-932) is now more user friendly.
• The Conversion Notice Form (G685-NY) is no longer available on HBA Online. If this form is needed for reason other than retirement (i.e., termination or dependent lost eligibility) you must contact EBD to request that the form be mailed to the employee.
• The Absolute Assignment forms (MM9343.SCRE and MM0602.SCRE) are no longer available on HBA Online. If an employee needs either form, you must contact EBD to request that the form be mailed to the employee.

For more information regarding M/C Life Insurance, including eligibility requirements, please refer to the M/C Life Booklet (January 2019, AL1646) or HBA Online.

If you have any further questions, please contact the HBA Help Line at 518-474-2780; representatives are available between the hours of 9:00 am to 4:00 pm, Monday through Friday.

Attachments: